james mcgee

Bethesda, MD

I administer a $120 million dollar employee benefit plan. My job will be less necessary in a single payer health care system, but I see daily that this employment based patient delivery system does not work.
And it is incompatible with the flexibility needed in a 21st century workforce.

http://http:\\thehealthcaremaze.us

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james commented on the article | over 1 year ago

Primary Doc: We Don't Like Gatekeeping, Either

I beg to differ.

The problem is not the concept. It is the implementation. As you note, primary care is important, essential, and efficient. More important, it can save lives. There is ample evidence that suggests that our overemphasis on specialty care does little to improve overall health outcomes; and - here is the important part - in the case of self referrals to specialty care may produce worse outcomes.

There are patients who know their own health status, sometimes better than their doctors. They are usually intelligent and sometimes write about their experiences. There are a lot more who cannot judge their own health status. They make snap judgements about what they need and go to a specialist who only know how to treat what they have been trained to treat. A primary care physician is an important, and I would argue, necessary arbiter in that process.

The very first implementation problem is our employment based system. I am going to guess that this was behind part of your own difficulty. It sounds like you got your new insurance plan at work and tried to find a doctor that would accept that insurance. Excuse me if I'm jumping to conclusions.

As you suggest the relationship between a patient and doctor needs to be a stable long term relationship. The outdated notion that our portal into that system should depend on an unstable employment relationship makes absolutely no sense at all.

The second implementation problem is the very concept of networks. The idea that these doctors are "in network" and those doctors are "out of network" makes sense only to insurance companies, who as you point out, don't have our interest in mind.

The next implementation problem is information technology. How much trouble is it to design an information system that permits you to call your doctor and your doctor will send an electronic referral to your specialist. I'm not a tech geek, but I suspect that capability has been around for a while. They could even build an indicator that says, referral not necessary.

I have gone to the same physician practice for my knees for the past twelve years. Fortunately, I don't go too often. But if I let more that two years go by, when I go to the doctor, they have all my personal information, my billing information and not a single bit of clinical information. Absolutely disgraceful.

We have a health care system that does not look past the next billing cycle, the next contract year, and is incapable of a long term patient view.

And the PPACA won't fix that.

http://thehealthcaremaze.us
james commented on the article | almost 2 years ago

The Price Tag of a Slow Death

What we pay as people with insurance does not reflect what the doctor (or hospita) is getting paid, unless he is balance billing for amounts in excess of the insurance company "allowance".

This totally chaotic payment system is one reason why there is so much fraud and abuse in the system - no one really understands it.

I recognize that we are in basic overall agreement. I just happen to feel strongly (did you notice?) that progressives fail to understand and confront this fragmented reimbursement system and it undercuts some of their shorter term objectives.

The subject of "buidling efficieny" could be a whole topic area at here at Change.org. I recently learned that a Platinum LEED certified building in this country would not meet minimum energy efficiency standards in many European countries.

Health care is not the only area where there are some lessons to be learned from Europe.
james commented on the article | almost 2 years ago

The Price Tag of a Slow Death

Harold

The reason that other nations do not experience "withdrwal of practice" is that the providers have two choices - treat insured patients and accept the negotiated prices or treat only private pay patients and take what that market will bear.

Here they want it both ways. How often have you gone to the doctor and been stuck with the difference between what the insurer pays and what the doctor charges? That is not an option in a single payer system or an all-payer/price reguated system.

The other difference is that other nations rely far less on fee for service payments and far more on global budgeting and capitation payments.

Use your example of New Jersey. And I am just guessing based on my experience. Hospitals budget pased on a "payer mix". So a hospital assumes 20% Medicaid, maybe 40% Medicare and 40% private (insured) payers. Based on that patient mix, it is probably getting 60% of its revenue from the private side and maybe 10% of its revenue from Medicaid.

Well if enough people are thrown out of work because of the economy and those private payers are now on Medicaid that has a drastic impact on the hospital's bottom line,

On the other hand, in a well regualted system, the hospital's income would not depend on who the patients were. The only thing that could impact the hospitals' bottom line is if the illness burden changed dramatically from one year to the next.

And the savings that would accrue to the hosptials by an immensely simplified billing system would benefit everyone.
james commented on the article | almost 2 years ago

The Price Tag of a Slow Death

I read this when it first came out. A very moving story, but not really helpful in terms of dealing with end of life issues.

I do take exception to one part of Josie's desscription.

"The rest of the money, for that surgery and countless other treatments, came from the insurance pool."

Not correct.

One of the failings of the current system is the way market share is used to leverae reimbursement.

Our (we progressives) failure to grasp how this principle distorts the market is one reason why the public option is gasping for air.

We think it is great that Medicare - or a public option plan - can use its "market power" to negotiate lower rates. But that is a failed model and the hospitals have so far blocked it from expanding into a "public option."

When one payer negotiates a lower rate with a hospital or a doctor, that provider has to make up their revenue shortfall (real or perceived) somehow. It will either charge higher rates to those with less "market power" (the uninusred) or it will refuse to treat patients with lower reimbursement rates. In some cases with private insurers, it can refuse to accept the insurance carriers reimbursement and balance bill the patient.

There are only two ways to avoid this shell game. The first is a single payer system. A single payer system would not have the luxury now afforded Medicare and Medicaid of setting rates confident that private payers will pick up the slack.

It will need to negotiate a reimbursement level that will keep its providers in business without making a killing (poor pun).

The other alternative is a system in place in Maryland (where I live). Maryland is the only state that sets rates for all payers for all hospitals. Medicare, medicaid and private insurers all pay the same rate. That model can be expanded to all providers and to all states. It would eliminate the reimbursement shell game with its mysterious "discounts" that are accounted for by some mythical "insurance pool".

That pool is someone else's pocket. It's what allows the insurance compnaies to make its gargantuan profits.

Levelling reimbursement rates would go a long way to eliminating treatment disparities. One of the way that doctors and hospitals avoid accepting lower reimbursement rates from Medicaid is by locating their practice where there are no poor people.
james commented on the article | almost 2 years ago

Note to Congress: Don't Forget the Kids

The bottom line is affordable quality coverage for all Americans. We should not settle fro anything less.

It makes no sense that one crosses some arbitrary income line or equally arbitrary age threshold or employement status and that then teleports them into some new and different world of health care.

Health care is not a privilege. it is not a gratuity to the vulnerable. It is not even a right. health care for all is in everyone's interest.
james signed the petition | almost 2 years ago

Health care Reform? We can do better! Much better!